Return on Community Investment (ROCI):
A High Impact Institute

Pre-Conference Data Collection
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Return on Community Investment Survey Responses

Respondent Name:

Mark Redding

E-Mail Address:

reddingz@att.net

Organization Name:

Community Health Access Project

Phone:

(419) 525-4649   Ext.

Fax:

(419) 525-2558

Address:

523 Park Ave East   

City, State, Zip:

Mansfield, OH    44905
Category: Your Community

What is the service area of your initiative (counties, city, etc.)?

2 census tracts in Mansfield (Richland Co), Eastern half of rural Knox Co, 3 census tracts in Columbus (Franklin Co)

What is the total population in your service area?

Richland Approx - 7000 Knox Approx 4000 (Rural) Franklin Approx 30,000

What percentage of the total population lives below the federal poverty level?

> 85% for Richland and Franklin, Knox similar with some rural areas in the region with a higher percentage.

What percentage of the total population is uninsured?

Richland Approx 20%, Knox 30-40%, Franklin Approx 20%
Category: Your Program Initiative

Indicate which of the following categories your initiative falls in:

Outreach and navigation
Common registration and enrollment
Securing public and private insurance coverage
Emergency room usage reduction
Case management of chronic disease

Describe the purpose of your initiative (in one sentence, if possible):

To improve health and social outcomes. Accountable outcome production strategies are integrated with the Community Health Worker model in a multi agency community wide intervention focusing on the most highly vulnerable families.

Describe the scale of your initiative in terms of budget, capacity, etc.:

CHAP employs CHWs in three counties actively serving a total of approximately 1200 extremely high risk clients. CHAP completes a total of more than 4000 accountable health outcomes per year using the Pathways model. Our yearly budget is approximately 1.2 million with variation related to grants and other funding. CHAP employs a development team focused on improving the model and assisting other agencies in deploying outcome focused strategies including CHW training, Quality Assurance, Database and Data Collection, Evaluation, Pathways Development etc.

Describe the operational components of your initiative:

as above

Describe your initiative's staffing level:

CHAP employs 18 Community Health Workers located in 3 separated county programs. Total staffing including full time consultants is 35. CHAP has a number of full and part time volunteers. Staffing in addition to the CHWs includes, Nurses, Physicians and Administrative/Fiscal staff.

If applicable, please describe your strategic use of an information system:

We have several and one Web system currently in development. All of our database systems are entirely focused on producing positive outcomes/Pathways. We have developed model structures for case management which allow supervision and accountable outcome production working with the most socially and medically at risk clients.

Please list the major, time-framed, measurable objectives your initiative is designed to achieve:

Achieve specific outcomes for risk scored clients in the most efficient and cost effective manner possible. Develop and distribute tools and structural program components that assist other programs in outcome production focus and cost effectiveness. Promote the state and national focus on reducing health disparities and achieving a more effective and integrated health and social service system, especially focused on families most at risk.
Category: Measurable Results

Which of the following results can be attributed to your program initiative? Please check all that apply.

Coordinated System of Care Savings
Reduction of ER usage for non-urgent care
Savings from operational improvements within integrated system
Qualifying people for government subsidized programs
Increasing awareness of programs and services
Services brought into the community
Volunteer contributions
Improved health status
Improved productivity
Economic development factor
Increased attendance at work
Increased attendance at school

Please list any other actual, measurable results of your initiative:

Starting in two census tracts in Richland Co Ohio with a defined 5 year rate of Low birth weight >24% we have achieved a rate of < 8% LBW for clients of similar risk living in the focus census tracts. We have utilized the model of Pathways to identify more than 30 defined health and social problems (i.e. high risk pregnancy, lack of immunizations, need for lead screening, developmental delay, unemployment, truancy, head lice etc). Using the step by step process of Pathways we have worked through evidence based interventions and documented the completion step (final positive outcome) for more than 6000 Pathways. Pathway production is measured regularly by Community Health Worker, by program and for our agency as a whole. We also assist our county now in measuring Community Pathways which document outcome production at a community wide level. Community Pathways are the most powerful version of the model as most outcomes require the collaboration of multiple agencies. Community Pathways allow multiple agencies to be held accountable to collaborative outcome production.
Category: Your ROCI Strategy

How do you define ROCI?

Evidence based interventions which improve health and social outcomes while saving short and long term expenditures.

Describe your ROCI objectives and strategy:

Define the problems. Define which problems are most important to address. Use geomapping and other strategies to find where the problem is most highly concentrated. Engage community members, service providers, agency leaders and others to build Pathways (outcome focused production tools) to address the problem. Deploy Community Health Workers (or other interventionists) to identify the clients in the focus area and case manage them through the evidence based steps of the Pathway. Track Pathway production. Evaluate each step of the Pathway to determine rate limiting steps (steps which are holding up the production of the positive outcome i.e. long waits for appointments, paper work delay etc) Learn from case managers who are the fastest/most effective Pathway producers. Communicate with participants/agencies, retool and train, focusing on increasing positive outcome production. Work to attain the highest level of outcome production with existing resources. Evaluate disparity reduction and cost savings. As outcome production increases local and regional percentages of outcomes will improve. The process of Pathways highlights that Pathways related to housing, food, clothing and other social issues must have a very high priority if medical issues such as prenatal care and ultimate positive birth outcomes are to be achieved.

Describe the players involved in the ROCI conversation (by title and/or function):

Continued from above - See above Pathways document that individual social/cultural issues must be tied in a common service product with the technical medical issues for that client. If social cultural issues are ignored technical medical capacity is irrelevant because the at risk client will never access or use the service. As effective outcome production and service strategies are identified, state and national stake holders must be engaged and policy retooled to help reduce disparities and improve cost savings.

List the milestones in your ROCI strategy that pertain to deal making (a prospective approach):

1999-2000 -Identified and employed Community Health Workers in 3 Counties 2000-2002 Established production/Pathways based contracts with Jobs and Family Services in two Counties. Established memorandums of agreement for more than 15 agencies in Richland County to participate in the community wide accountable model of Pathways.

List the milestones in your ROCI strategy that are tied to outcomes (a retrospective approach):

above

List the milestones in your ROCI strategy that are linked to sustainability:

July 2003 - Legislation signed into law for Community Health Worker Certification under the Ohio Board of Nursing
Category: Your ROCI Methodology

Describe the analytic or economic logic underlying your ROCI method:

Example - One prenatal visit for an economically disadvantaged pregnant woman can reduce preterm delivery by 50% (ACOG reference available reviewing 11 million births) We currently provide services in an area where 24% of women have a low birth weight baby. LBW costs tens of millions in the most severe cases and all LBW infants are 50% more likely to need special education etc. We have a collaborative agreement with Ohio Medicaid to review birth cost information for clients who receive a Pregnancy Pathway versus those who do not in our high risk focus census tracts. We are comparing these cost and early analysis is showing very positive results. We have also calculated through careful time and resource tracking the cost to case manage and build a Pathway. If the cost to build a Pathway is known and the specific cost savings is known the ROCI is able to be calculated. We hope to publish this data by summer 2005. We have already provided limited publications demonstrating LBW improvement from 24% to < 8% for enrolled at risk clients in our service area.

Is your method supported by scientific research? If yes, please describe:

as above

Describe the measures that you used to define "returns" or value:

as above

Describe the measures that you used to define investments or costs:

As described above we have calculated the costs of building Pathways by utilizing a time sheet that requires the Community Health Worker to document in 15 minute blocks the exact amount of time they work on each Pathway. In doing a home visit on a pregnant client they may spend 30 minutes on the Pregnancy Pathway 15 minutes on the Homeless Pathway, and 15 minutes on the Employment Pathway. When the Pathway is completed the total time it took to complete the Pathway is added up. The number of hours for the Pathway multiplied times our unit rate for service (the unit rate includes Admin. costs etc) = the cost to build the Pathway. This can then be measured against the cost savings for the positive pregnancy outcome employment etc.

Please briefly describe your data collection methods.

Check lists have been developed for Pregnant, child, infant etc. The checklist has ''Trigger Questions'' which when answered yes tell the CHW and Supervisor that a Pathway may be needed. For example ''Do you need health insurance?'' If answered yes would trigger the health insurance pathway which starts with the client having no health insurance and ends only when health coverage has been confirmed (Medicaid, Private, ''free care'' etc.). Each step of the Pathway is documented with time completion and comments. When the Pathway is completed and confirmed by the Supervisor it is credited to the CHW and the program. Case notes use the SOAP format with the client plan in most cases entirely made up of Pathways in various stages of production.
Category: ROCI Communication and Negotiation

Describe the conversations that define your ROCI process:

Focus on outcomes. Focus on increasing accountability. Agencies must work together as collaborative teams and be held financially accountable for producing specific outcomes. When accountable outcome production is deployed often technical medical capacity is not identified as the rate limiting step of the Pathway. Client's are not accessing the system due to trust, lack of understanding of the importance of health care, long bus rides, lack of phones, basic survival issues which take priority.

Describe how ROCI conversations are tailored to specific audiences:

Funders - Pathways allow you to receive a specific auditable financial deliverable in a dollars for outcome approach. Communities - Our whole model demonstrates that communities must be engaged as key members of the health and social service team for outcomes to improve and disparities to be removed. Political Representatives - Saving dollars, improving the health of children and families, saving lives

Describe what enabled effective conversations to occur:

Engaging key communicators and persons capable of networking at the community, county and state level
Category: Results from the ROCI Process

Describe the outcomes, the successes of your ROCI strategy:

Above
Category: Lessons

What do you see as the critical success factors that can guide others?

Above

Do you believe that your results can be replicated successfully with other similar initiatives? Can you suggest how replication may be facilitated?

Yes - Our model is being used County wide in Richland County. Agency Pathways are being used in more than 5 agencies across the state with a total of more than 15 different locations for outreach. We have provided our outcome focused CHW training to more than 300 Community Health Workers across the state.
Category: Share Your Resources

Resource Files you've shared with us:

CHAP Description.doc
CHAP Pathways Manual.doc